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New Mexico Reduces
Avoidable ED Visits with Technology
Session 277, February 14, 2019
Beth Landon, Policy Director, New Mexico Hospital Association
Benjamin Zaniello, MD, MPH, Chief Medical Officer, Collective Medical
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Beth Landon
• No real conflicts of interest to report
Conflict of Interest
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Benjamin Zaniello, MD, MPH
• Dr. Zaniello is the Chief Medical Officer of Collective Medical and
a full-time employee of, and equity-holder in, Collective
Medical. He is also a practicing physician at Washington-based
Providence St. Joseph Health, which is an investor in Collective
Medical.
• This makes him both incredibly biased in favor of Collective
Medical and Seattle-based sports teams.
Conflict of Interest
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New Mexico – At a Glance
LANE (Low-Acuity Non-Emergent) ED Visits
First Attempt
ER is for Emergencies
Care Collaboration
Befriending the Frenemy
Results
Looking Forward
Q & A
Agenda
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Learning Objective 1
Discuss the steps involved in implementing a statewide program for sharing
information
Learning Objective 2
Identify and incorporate the right technology tools to detect high-utilizers of
ED services
Learning Objective 3
Evaluate ways of gaining alignment among individuals and organizations
resistant to change in order to foster collaboration
Learning Objectives
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• 5
th
largest state in landmass (121,298 sq. miles)
• home to 2.1 million people
• 48% Hispanic & 11% Native American
• 20% Medicare
• 42% Medicaid
• roughly 80% of New Mexico births are Medicaid
• 852K people on Medicaid
• approximately 50K people with market coverage
• poverty is our common enemy
New Mexico – At a Glance
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Our Journey – Reducing LANE
New Mexico Medicaid instituted LANE efficiency adjustments for
prospective rating periods.
“As a prudent purchaser of healthcare services,
the State expects the MCOs to improve when possible
and not perpetuate unnecessary costs going forward.”
LANE (Low-Acuity Non-Emergent)
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• Representatives of all 4 Medicaid MCOs:
• Blue Cross and Blue Shield of New Mexico
• UnitedHealthcare Community Plan of New Mexico
• Molina
• Presbyterian Health Plan
• Facilitated by an MCO Medical Director
• New Mexico Hospital Association invited to participate July 2015
MCO “Liaison” Meetings
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“Contractor may utilize a list of diagnoses or symptoms to identify
potential claims that should be reviewed under the prudent layperson
standard for payment integrity purposes. Emergency room claims for
services provided to any member may be reviewed before or after
payment and payment for post-stabilization services may be denied
when the services rendered after the initial screening, evaluation, and
stabilization were determined to be medically unnecessary after a
clinical review.“ (Source: email from New Mexico Medicaid)
First Attempt: Don’t pay LANE claims
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“It is no longer possible under federal
rules to deny a claim for unnecessary
use of the ED” (Source: CMS to State Medicaid office)
First Attempt: A Bust
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• Only non-emergent if qualified by an emergency physician
• Physicians need to consider the time of day/resources
The same condition may be considered an emergency at 10 pm on
a Saturday night, that would not be considered an emergency at 10 am
on a Tuesday—a non-emergent situation cannot be identified by the
medical data on the claim.
First Attempt: A Bust
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A non-emergency use of the ED is when the ED…
…performs the initial triage
…informs the patient that it is not an emergency and provides proper
alternative care settings (i.e., other resources in the area or visiting the
PCP the next day)
…informs the patient that if they want services performed in the ED
beyond the initial triage, their ED visit will be declared an unnecessary
use of the ED and a co-payment will be assessed
First Attempt: A Bust
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A. If the patient chooses to continue with treatment beyond the
triage stage, the hospital must show on its claim they assessed
a co-payment indicating unnecessary use of the ED.
B. If the patient chooses not to continue with the service beyond
the triage stage, the hospital still bills the ED claim
First Attempt: A Bust
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Situation
• Disproportionately small number of patients (<5%) generate a disproportionately
large number of ED visits (~21%)
• Most pathologies present in the ED over time
Complication
• Challenging to coordinate ED-to-ED care across disparate health systems
Result
• Suboptimal clinical outcomes (opioids, psych, etc.)
• Poor provider resource utilization
ER is for Emergencies
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Program results
• Washington saw a 10% drop in total Medicaid ED visits
year-over-year (~$34M savings)
• Hospitals report a 60% reduction in ED readmissions and a
30-day inpatient readmission rate reduction from 25% to 6%
• Washington (statewide) saw:
• 24% Reduction in ED visits with opiate Rx
ER is for Emergencies
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Collective Medical was implemented as the
care coordination technology backbone of Washington state’s
“ER is for Emergencies” program
Vendor Selection:
• Issued an RFP
• Collective Medical won the bid
ER is for Emergencies
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• Exclusively endorsed by the American College of Emergency Physicians
• Emergency physicians are on board
• Molina used Collective in other states
• 2400+ ACOs, Plans, Hospitals, & Clinics on the Network
Why Collective Medical
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Goal is Care Collaboration
Comprehensive Data
Risk Identification
Targeted Notifications
Collaborative Workflows
• Thin slice of real-time clinical data spanning all visit encounters at
each participating care venue
• Low-lift for participating providers
• Real-time detection of the highest-risk individuals entering each
facility
• Frequency, prescriptions, security, readmissions, diagnoses x
demographics, managed patients
• Targeted, push-based, real-time alerts with patient specific info to
enable actionable next steps
• Sent to providers at the point of care and longitudinal care provider
• Single playbook from which to coordinate individualized patient
workflows across all stakeholders
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Result:
Actionable
Shared patient
info, at any
point of care
Care Collaboration in Practice: Notification Engagement
• Notifications are delivered in the EMR
for immediate, in-workflow access
• 3+ care providers are accessing each
notification in this sample hospital
network (24 individual facilities) over
one year
• In-platform contribution rates are similar,
showing users consistently adding
patient care plans and recording
security/safety events
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Care Collaboration
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Pacific Northwest 2012
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Pacific Northwest 2013
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Pacific Northwest 2014
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Pacific Northwest 2015
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Pacific Northwest 2016
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Pacific Northwest 2017
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Pacific Northwest 2018
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New Mexico 2018
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• Molina Medical Director / NMHA Policy Director Co-chair
• Meet in-person for 2 hours per month
• What about Indian Health Service? VA? FQHCs?
• Prescription Drug Monitoring Program?
• Summer of 2016 – Collective Roadshow to all hospitals
Befriending the Frenemy
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Hospitals
• 8 hospitals live in June 2017
• 25 hospitals live in August 2017
• 32 of 37 hospitals live today
FQHCs
• 7 live
Indian Health Service, SNFs, psych hospital to follow
Veterans Administration
Going Live
Care Collaboration in New Mexico:
Hospitals and Health Plans are now sharing data with each other
• Only four non-federal medical centers still in process
• Indian Health Service and Veteran’s Administration hospitals in
discussions
Care Collaboration in New Mexico:
Hospitals and Health Plans are now sharing data with each other
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Results & Success Stories
16,842 Average monthly notifications sent to New Mexico
264,197 Total number of alerts since go-live
For participating organizations:
• BCBS NM created a congestive heart failure program with
community paramedics
For patients:
• a patient visited the ED 262 times in 12 months, related to
homeless and substance use disorder (SUD)
• real-time notifications allowed a community health worker to
establish contact and help him find housing and get SUD
treatment
• patient has only visited the ED 18 times in the last year
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New Use Cases
• Notifiable conditions tool
• Change in opioid prescribing
• Health risk assessments
• Expanding access to the Collective Network
Care Insights
Statewide Learning Collaborative 2019
Looking Forward
